St. Anthony College of Roxas City, Inc. (Hospital) San Rogue Bx, Roxas Cy name of Patent: ae sox Attending Physician/s: Whe, Rm. No.: PATIENT DISCHARGE INSTRUCTION SHEET [EMR a ra aT —erarng | Sei Consideration/s — TL SPECIAL CARE INSTRUCTIONS: Diet/Nutrtion: Regular, no restrictions sot diet [-—Joiet as tolerated aland cet [——JHvpo-atiergenic diet Ce let Low sat, low fat, Not specified ACTIVITES (the patient can involved in): As tolerated Jothers (ps. spect “OTHERS (Laboratory, X-Ray, ete}: ll, RETURN TO CLINIC/FOLLOW-UP CARE ON: Date: Time: WV, DISPOSITION: May Go Home Patient Transferred to other Hospital ‘Name of Hospital: Patient left AMA Instructed by: Location: Received by: Nurse's Signature over Printed Name Date and Tie Patient [Representative Signature over Printed Name (Please accomplish in duplicate copies, attach one to the chart and the other as patient's copy.) Controlled copy: Uncontrolled if printed or copied. Check the original for conformity. OF-Ns-016 ‘apes/os-2001